Jeffrey Lowenkron, MD, MPP, Chief Medical Officer, The Villages Health

During your time at The Villages, have you observed progress in patient empowerment over care planning and more use of palliative aid to avoid unnecessary invasive treatment at the end of life?

I would say, unfortunately, no, and it’s not because we don’t have time. Any time you look at anything that’s been evaluated over the last couple of decades related to end-of-life care, it’s not the patients. The patients have already thought about it. They know what they want. They’re really hoping somebody would ask them. We never ask them. In primary care, I don’t know the numbers now, [but] it used to be about 4% of the time we asked them, even though 80% of the time they thought about what they wanted and knew. I would say the only group that’s probably worse at doing advanced directives and palliative care than primary care is oncology. For the folks that have oncology problems, the likelihood that they’ll get palliative care at the right time or even hospice at the right time, I would say it’s unfortunately delayed.

Is the expansion of Medicare Advantage a plus or a minus for oncology care in your view?

I think the expansion of Medicare Advantage, it’s always a plus for the patient. Because what Medicare Advantage does, as opposed to the fee-for-service world, is it links and aligns patient outcomes with care delivery. As patients do better, the care delivery systems do better, and as patients do worse, the care delivery systems do worse. In the typical fee-for-service model, generally the care delivery system can do really, really well, and the patients may do very, very poorly. They don’t have to align. From the perspective of the patients, it’s always a better care model and payment model to be in Medicare Advantage than traditional fee-for-service.

From the oncology perspective specifi cally, there are going to be some challenges because obviously with the expansiveness of very expensive medications in the oncology world, the diffi culty of fi guring out how to pay for those is a real challenge. I can’t tell you whether it’s going to be better or worse for them over time.

Maen Hussein, MD, Physician Director of Finance, Florida Cancer Specialists 

What will CMS’s proposed change in the way Medicare Advantage pays for hospice mean for community oncology practices?

I think that hospice is being underutilized in caring for our patients. There is this mentality that hospice means that the patient is going to die very soon. That’s really not true. There are more data showing that palliative care and hospice actually help improve the quality of life, and in some cases, even survivorship. I believe that the new changes will help and encourage the oncologists to bring up that topic sooner than later, and maybe help the patient accept that concept, and change the culture to understand that being under hospice care doesn’t mean you’re dying tomorrow. The indication for hospice, if the patient has survived, it’s less than 6 months, and that actually can be extended. It doesn’t mean that you’re even dying within 6 months, but that’s usually the period and if the patient lived to 6 months, you can even extend that. That will encourage the physicians to approach the patient sooner than later; talking about the option of hospice. I can see that culture change. I’ve been practicing here for almost 15 years now. It was much harder to talk about hospice before than now, especially when you explain to the patient that this is not the end, you’re not giving up. But it’s a way to focus on your pain and discomfort and still allow for some palliative therapies. A lot of hospice now are [willing] to pay for radiation therapy as palliative [care], or even sometimes some forms of chemotherapy.

The Oncology Care Model (OCM) has been criticized for failing to adequately account for high-cost drugs for some patients. Have you seen improvements in the proposed Oncology Care First model and which proposed change do you believe is the most important?

I think it’s still early to judge if the changes [will] have an impact. I think one of the things that seemed to be promising is that they have the risk assessment for each cancer, so they have the risk stratifi cation. That might help in the future to assess for each type of cancer, how much it will cost to treat those patients. That will help in the bundled payment in the future.

Rebecca Kirch, JD, Executive Vice President, Health Care, Quality and Value, National Patient Advocate Foundation

What obstacles continue to prove an issue within oncology? What further research is warranted to address these issues?

There are some interesting challenges in the form of language barriers, and old habits that die hard. [At the meeting of the Association of Community Cancer Centers,] we talked about the importance of integrating palliative care, and the fi rst question was, “Well, who provides that?” Depending on when you were trained in your practice, you might have learned palliative care as something diff erent from what it is today and what the evidence shows. So today, what palliative care is, is an essential aspect of good quality cancer care from diagnosis onward to optimize quality-of-life.

Whose job is it? It’s everybody’s job. Every clinical encounter needs to include some aspects of helping with care coordination, identifying what’s bothering the patient and caregiver most, because they’re an essential unit of care. The opportunity we have to use the skilled communication that is sort of at the core palliative care principle for all frontline clinicians to be equipped and confident and engaged in doing, I think will make a significant diff erence for how value-based care unfolds, how payment reform happens, how the lived experience plays out for patients and families to be a better one, irrespective of the prognosis of the trajectory.

If we emphasize the importance of those skills, and the opportunities to address financial impairments and functional impairments through navigation to these services that people need that focus on what they say matters to them, then we’re delivering truly person-centered care and the promise of what that can be. If we keep emphasizing diseasedirected treatment without thinking about quality-of-life, and the person beyond the disease, we’re going to fall short of all of those goals that we all hold dear.

Michael Diaz, MD, President of Community Oncology Alliance and Assistant Managing Physician at Florida Cancer Specialists

In its response to the Oncology Care First request for feedback, COA recommended a delay in the start of the successor model to January 1, 2022. How will having more time in the OCM benefit practices?

Well, there are several reasons. First of all, 2021 is less than a year away, and we don’t have details on this new model. In order to have practices evolve, change, and implement new processes — and I think that’s one of the key things here &mdash; there are a lot of new fundamental components that are diff erent than the Oncology Care Model (OCM). We want to make sure that practices have adequate time to learn, understand, adapt, and modify. We’re wanting to extend the Oncology Care Model in essence, to actually delay the initiation of the Oncology [Care] First model. That’s the most important thing. Some people will say, “Well, why can’t you just complete the Oncology Care Model, delay the Oncology Care First model 6 months to a year?” Well, all the practices already had this infrastructure set up for this type of system process. We have care coordinators, we have layers and layers of new systems that we’ve developed to be able to participate in these value-based care models, these alternative payment models. Without participating in a model, you can’t keep and maintain your fundamental infrastructure. The majority of the practices, we feel, would experience some financial hardships trying to maintain those components of their practice if they’re not participating in them all. We just think that it would help ease a transition.

Another more significant reason has to do with the fact that the Oncology Care First model, when you start in it, right now, the way it’s designed, you start off in a 2-sided risk. We would like for as many community oncology practices to be able to participate in this, and not all are participating in the 2-sided risk of the Oncology Care Model. We just think a delay would allow more time to allow more practices to evolve to be able to participate.

Are you receiving any early feedback from practices that have moved to 2-sided risk?

We have been hearing from other practices. I think that because right now we’re still getting feedback from the later performance periods, before people had to switch in 2-sided risk, we’re getting mixed results, because not everybody is in 2-sided risk in the first place. Those that have gone to 2-sided risk, some are doing extremely well. I have not heard from those that are in 2-sided risk and have not done well. The only other things that I have heard is that as we proceed, and we get data from subsequent pay periods, things are changing and people aren’t performing as well as they thought they might. They’re not sure why but there’s just a delay in the time required for the feedback. I haven’t heard anything from the practices since we had to decide to accept the 2-sided risk model for this period, but I’m sure that we will hear more as time evolves. That’s another reason why it wouldn’t necessarily be a bad idea to sort of delay the initiation of a new model, because the amount of time in between the period during which we’re taking care of patients and the time we get the feedback, there’s such a delay. It’s a little diffi cult to make changes very quickly, because we just don’t get the information very quickly. We just need the time to improve our processes. If we could narrow down the time interval from when we are seeing patients in the performance period to the time we get the information results and understand why we did how we did, if we can get that time interval narrowed down, then it would probably be easier to transition and evolve at a faster rate.

Cancer Specialists can share with other community practices that are moving to alternative payment models?

What are the most important lessons from the OCM that Florida 

I thought about this because we’ve been working at this very diligently for the past several years. I would say, it takes a lot of collaboration. You need to network with the other practices involved. You need to share ideas. You need to network with specialists that understand the data that you’re receiving from CMS. Because whenever you get the data, it’s not very easy to interpret or understand, so you need to work with a specialist that can help sift through all the details so that you can understand why your practice performed the way that you did. Until you know that information, it’s very difficult, very difficult to make improvements. Networking, working with experts, I would say those are the main things. Also, you have to get the physicians involved and you have to get their buy in. They have to really understand the importance and believe in it and understand why they’re doing it. I think that if you get all those major components aligned, along with having very good management, practice management that can sort of glue all that together, I think that helps to optimize success in any form of alternative payment model including Oncology Care Model.

Lucio Gordan, MD, President & Managing Physician, Florida Cancer Specialists

In your opinion, does the proposed Oncology Care First model go far enough to address concerns that the OCM did not adequately reimburse practices for high-cost therapies? Why or why not?

The Oncology Care First model remains very diffi cult to understand, in my opinion. I think Community Oncology Alliance and others have sent several initial suggestions and recommendations to CMS, CMMI (Center for Medicare and Medicaid Innovation) as t o how to design Oncology Care First. I am not convinced yet that Oncology Care First truly takes into account the necessary elements, including high-cost drugs. I think we lack understanding as far as the details, as to how this will be operationalized. We really have embraced the Oncology Care Model. We do think that value-based care should obviously continue in cancer care in the United States. It is just taking maybe too quick of a step from moving from the current Oncology Care Model to Oncology Care First. There are a lot of things that need to be understood and the details need to be ironed out for us to truly embrace this as a solution for us.

Have you seen any shifts that suggest payers are recognizing cost differentials between hospital and community oncology settings in cancer care?

I have seen a significant improvement in understanding of the site of care issues as far as cost, as we compare hospital systems versus community oncology. Išhaven’t seen enough action and results yet. Clearly, the payers do understand the dynamics and the importance of fi xing the issue. Hopefully we’ll get there. The steps have been small and moving slowly, but I’m relatively optimistic that we’ll get there, hopefully in the near future, as far as improved transition from site of care from hospital-based to community-based systems.

Articles

Evidence-Based Oncology

Excerpts from interviews with faculty from Florida Cancer Specialists, The Villages Health, and the National Patient Advocate Foundation.

AJMC® INTERVIEWS: Faculty From the Institute for Value-Based Medicine

“Help me. I’ve never seen death before. Tell me what you know about it; what you’ve seen. What was it like to witness your patients leaving this world? Tell me how you coped with it. Aren’t you afraid of death yourself? … Can I prepare for my own death? Can I prepare my dear wife and daughters? … I need to know what happens when people die. I’d like to know so that I can plan my own exit. I want to go away in celebration, not gloom.” …

“Yes, I can definitely share my journey with you. I will also share some of my other patients’ stories with you, if you believe they will help.…When do you want to begin?”

“Maybe we can meet once a week at lunch time, here under this beautiful copper dome. Could we start tomorrow?”

So begins a series of conversations which unfold in the captivating relationship between Harry Falls, a former pilot with the British Royal Air Force and later a flight instructor in the United States, and Kashyap Patel, MD, author of 

Between Life and Death: From Despair to Hope,

 which will be available soon from Penguin Random House India. Production delays due to coronavirus disease 2019 will require the April 2020 launch date to be rescheduled. (See 

) will recognize Patel as an associate editor and contributing author. Patel is a medical oncologist/hematologist and the chief executive officer of Carolina Blood and Cancer Care Associates, based in Rock Hill, South Carolina. Having grown up in India and practiced medicine on 3 continents, he has devoted tremendous personal time and travel to nourish his interest in world religions and cultures—particularly to gain insight into the universal human experience of death.

Falls, married to one of Patel’s colleagues, died within months of a diagnosis of lung and liver cancer. Yet, amid the challenges of his illness, Falls was incredibly fortunate. He had the rare opportunity to discuss his questions about death with Patel, a physician and friend who was exceptionally well-equipped to help Falls prepare for what the aviator called his “ultimate and infinite journey.” Throughout the last months of Falls’ life, the pair met weekly to examine death from multiple vantage points: physical, emotional, relational, cultural, and spiritual—religious–philosophical. Their encounters provide the foundation of 

Patel’s medical facility was well-designed for conversations with Falls. The doctor explains, “My clinic, Carolina Blood and Cancer Care, was founded on a holistic approach to the treatment of cancer. We constructed the building with a U-shaped design that allowed all patients to look out onto a healing garden with a gazebo topped by a golden dome. When weather permitted, patients could receive their chemotherapy treatments outside on the patio or under the dome. It wasn’t just for the patient’s comfort. During difficult discussions, a quick glance at the garden in bloom or the smile of a patient resting in the sun grounded me, put life in perspective, and reminded me of my mission of service.”  Patel’s clinic was an early adopter of the patient-centered cancer care model designed to serve holistic needs of patients, with a focus on palliative care.

, Carolina Blood and Cancer Care Associates has been one of the most successful practices in the country in executing alternative payment models (APMs), which gives practices more support to help patients with advanced care planning.

 But when Patel and Falls were having their conversations years ago, these ideas were still new, and support systems like the one that Patel created for Falls were harder to find.

The healing garden is the recurring setting where readers of 

will vicariously accompany Falls along his journey toward death. Pondering his grim diagnosis, Falls decides not to pursue chemotherapy or any other treatments, because they would involve diffi cult adverse eff ects and would be unlikely to prolong his life significantly. “After evaluating where I stand and how I’ve lived all these years, I feel it would be best for me to start packing my bags for the ultimate and infinite journey. … God blessed me with a life that I have no regrets over … Let’s face it, Doc. From everything you’ve told me, treating my cancer is like trying to save an exploding plane in mid-air. Chances are it’s not going to happen. … I think of it like I’ve just received an upgrade on a long fl ight. I’ve collected so many miles that God has granted me a charter flight to a destination unknown. Now the only issue is the waiting time.”

Doctors have debated for more than 20 years on how to engage cancer patients in the decision-making conversation once they have reached the terminal stage.

 The culture of care in the United States suggests that Falls is an exception, with language around treatment calling on patients to “fight” cancer even when it cannot be cured. A 2019 study of 20 women with metastatic breast cancer found that “patients’ definition of a good compassionate doctor was one who gives positive news and leaves room for hope.”

Another study published last year found that 28% of patients with imminently fatal colorectal cancer received treatment , even though this can prevent palliative care.

Patel writes, “Even when I was seeing patients with very advanced cases where I knew they were better off dying peacefully than going through the pains of chemotherapy, which bought them maybe a few more weeks, almost every patient I came across was adamant about hoping for a miracle. But Harry was different.”

Falls decides he will not pursue extraordinary measures to avoid death, but he has an extraordinary curiosity about the dying process, which Patel strives to appease. Upon receiving his terminal diagnosis, Falls says, “Doc, I’m not a religious or ritualistic individual. I’m somewhere between a non-believer and an agnostic. But I have some fundamental existential queries that are haunting me. … I want to know how death has been defined all these millennia. How do people die? Did our ancestors understand death in a similar fashion to our understanding? How did they treat the bodies after death? How was this diff erent across cultures? What about the afterlife? What is a good death, or rather, what does it mean to die well? I can handle a mid-air somersault and navigate the worst turbulence. But I am totally incapable of even remotely imagining my own mortality and afterlife.”

Patel responds, “I wish everyone facing death, which is in fact everyone someday, would spend time thinking about these questions.”

Patel comes to the conversations with immense cross-cultural knowledge. The reader is drawn in by poignant stories of a doctor and his terminal cancer patients, which stimulate Falls’ discernment about how to spend his final days meaningfully, and about disposition of his body after death. For example, Patel introduces the Indian custom of a funeral pyre, and describes how he fulfi lled the traditional ceremonial role of igniting his brother’s funeral pyre. He explains beliefs and rituals associated with death in ancient Egypt, Greece, Rome, and Australia, and in Hinduism, Buddhism, Judaism, Catholicism, evangelical Christianity, and Islam. He delves into topics not normally covered in a physician’s training, such as the human soul, possibilities for an afterlife, and the meaning of suffering. 

Although his cancer is not cured, Falls satisfies his human need to prepare for a peaceful death. Readers will not want to put the book aside until they learn how Harry’s story ends.

, is to prompt communal and personal preparation for a profound human experience that is unavoidable, yet—paradoxically&mdash;too seldom a subject of open conversation. Patel thinks humans will have more meaningful and comfortable experiences of death if their community does not treat death as a taboo subject, or an event to be delayed through extreme, often painful measures that yield meager improvement in longevity or quality of life. He writes:

I see it every day; patients in their last few days enduring horrifi cally painful therapies when we have already informed them that the end result of that dreadful suff ering will be maybe two or three more weeks of life spent in agonizing pain. The pain and the therapy do not allow them to spend time with their loved ones or enjoy the comforts of life. Those few weeks are spent chained to a hospital bed. We are too willing, it seems, to bargain away quality time with those we love and freedom from debilitating pain in exchange for fourteen to twenty-one more days on earth. And in that last leg of the marathon, instead of preparing and planning for a graceful and pain-free departure surrounded by those we hold dearest, we prefer to ruin those last, most precious moments in pursuit of a farfetched cure, ensuring that the final days we spend on earth are the most miserable of our entire lives. It is this fate that, as a physician who has been at the deathbed of countless numbers of my patients, I want to help people avoid.”

As Patel shares stories of his deceased patients, it’s evident that they have benefi ted from a highly attentive physician. He accepts their calls to his cell phone at all hours; he visits their homes; he attends their funerals. Readers who have struggled to schedule appointments with their physicians may be astonished at the generosity of the time spent with Falls. Yet, from an ethical perspective, 

raises serious systemic concerns about empowering patients to exercise genuine informed consent. How much is informed consent for end-of-life decisions undermined—or impossible&mdash;for countless patients who begin the dying process as Falls did, but never have the opportunities for education and reflection that he received?

Like Harry Falls, many patients, caregivers, and medical professionals lack guidance or opportunity to prepare existentially for the dying process before they are thrust into it. In the era of quality metrics in healthcare, the HealthCare Chaplaincy Network has developed a measure for comprehensive palliative care that includes relief of existential or spiritual distress, which can be as burdensome as physical pain.

 Guidelines from both the National Comprehensive Cancer Network

 and the Healthcare Chaplaincy Network call for palliative care to begin well before a terminal patient is admitted to hospice care. Patel has previously published critiques of the medical profession’s insufficient training for managing the holistic needs of dying patients.

, he says, “End-of-life discussions are the most difficult part of my job”; yet, repeatedly, he states that nothing in his medical school training prepared him for this role.

That structured medical education largely neglects end-of-life-discussions might be considered tolerable for physicians who are less responsible for delivering terminal diagnoses—but certainly not for an oncologist. In the interview with 

, Patel was asked whether skills for conducting end-of-life-discussions can be eff ectively taught to medical professionals. Patel said he thinks that improvements in structured training are certainly possible and much needed. He has sought this training for himself—for example, by becoming a certified trainer of physicians through the Education in Palliative and End-of-Life Care program affiliated with Northwestern University’s Feinberg School of Medicine.

Mindful of the losses Patel has endured with his dying patients, Falls and other characters in 

ask him questions such as, “Doc, how do you keep doing this?” … “Don’t you ever get burned out … from doing this over and over again?” … “Does dealing with death not affect you, your personal life?” Research indicates that these are precisely the sorts of questions medical professionals should be taking seriously. Burnout, trauma, posttraumatic stress disorder (PTSD), depression, and struggles with work—life balance are more common in the medical profession than many realize.

At several points in his book, Patel notes that professionals like himself are expected to “remain emotionally detached” or to “rein in [their] personal emotions” when engaging with patients, but he “had never been fully successful” at doing so. But why should professional “success” be measured by the criterion of emotional detachment? Those who approach death from a more pastoral or therapeutic perspective will be concerned that medical professionals like Patel need healthy ways to process their human emotions. Patel admits to Falls, “As an oncologist it’s always been my job to guide patients through their own grief. I can’t burden people facing death themselves with my own sorrows at death’s hands. I try not to burden even my own family and try to shelter even my dear wife from it. Sometimes, I wake up in the middle of the night questioning my own judgment about what I have learned. I should thank you … I rarely have an outlet for my own grief.”

When asked about available resources to facilitate and de-stigmatize emotional supports for medical professionals who experience grief, depression, trauma, PTSD, or stress and exhaustion related to care for dying patients, Patel agreed that “a lot more could be done” in all these areas. In 

 Patel describes instances when he found himself tragically torn between special events with his family and untimely requests to tend to dying patients. On one occasion when called to the bedside of a dying patient, Patel felt compelled to cancel plans to attend the wedding of a daughter of one of his best friends. He asks for forgiveness from his wife who is left to attend the wedding alone. While these struggles are not unique to the medical profession, mission-driven medical providers in high-stress roles should have supportive employment structures that allow them to maintain their physical, emotional, and spiritual health—which Patel’s practice has pursued with a team-based approach, supported with APMs.

 is an accessible narrative that will be marketed for broad readership. Patel writes that he hopes this project will contribute to transforming cultural attitudes and institutions, such that planning for “a smooth, graceful and celebratory death and departure” is no more unusual or taboo than preparation for birth. This book is an excellent choice for professional development and personal enrichment. Beyond obvious audiences, such as medical professionals, grief therapists, and chaplains, it could be a powerful selection for community book clubs, or as an interdisciplinary shared reading assignment for first-year university students. Patel models a mature level of interdisciplinary, cross-cultural, and interfaith literacy which, ideally, should be more the norm than the exception. To reach the broadest possible audience, 

could be transformed into an outstanding theatrical production or screenplay—with the healing garden at center stage.

Kashyap B. Patel, MD, is a medical oncologist and hematologist who serves as chief executive officer of Carolina Blood and Cancer Care Associates in Rock Hill, SC. He is a national leader in clinical trials, precision medicine, the use of biosimilars, state and federal legislative affairs, and healthcare management. Patel has been an independent contractor for Palmetto GBA and currently serves as vice president of the Community Oncology Alliance and as a trustee of the Association of Community Cancer Centers.

Florence Caffrey Bourg, PhD, is an adjunct faculty member in the Loyola Institute for Ministry, New Orleans, LA, where she developed multimedia materials and the course textbook for Spirituality, Morality, and Ethics, a required course for graduate and certifi cate students training in the LIM program for various ministries, including hospital chaplaincy. She received her PhD in theology, with specialization in ethics, from Boston College, and is the author of 

Where Two or Three Are Gathered: Christian Families as Domestic Churches

1. Patel K, Patel M, Gor A, et al. Oncology practice transformation helps deliver patient-centered cancer care in a community oncology practice. Am J Manag Care. 2018;24(5 Spec No):SP147-SP148.

2. Patel K, Patel M, Lavender T, et al. Two-sided risk in the Oncology Care Model. Am J Manag Care. 2019;25(6 Spec No):SP216-SP220. 

3. Asai A. Should physicians tell patients the truth?.West J Med. 1995;163(1):36-39.

4. Bergqvist J, Strang P. Breast cancer preferences for truth versus hope are dynamic and change during late lines of palliative chemotherapy. J Pain Symptom Manag. 2019;57(4):746-752.£doi: 10.1016/j.jpainsymman.2018.12.336.

5. Sineshaw HM, Jemal A, Ng K, et al. Treatment patterns among de novo metastatic cancer patients who died within 1 month of diagnosis. JNCI Cancer Spectr. 2019;3(2):pkz021. doi: 10.1093/jncics/pkz021.

6. What is quality spiritual care in healthcare and how do you measure it? website.  healthcarechaplaincy.org/docs/research/quality_indicators_document_1_16_2020.pdf. Published January 16, 2020. Accessed

7. Dans M, Smith T, Back A, et al. NCCN Guidelines Insights: Palliative Care, version 2.2017. J Natl Compr Canc Netw. 2017;15(8):989-997. doi:10/6004/jnccn.2017.0132.

8. Patel K, Kruczynski M. Palliative and end-of-life care: issues, challenges, and possible solutions in the United States. Am J Manag Care. 2015;21(6):SP195-SP196.

9. Home page. Center for Bioethics and Medical Humanities at Northwestern University website. bioethics.northwestern.edu/. Accessed March 24, 2020.

10. Lazarus A. Traumatized by practice: PTSD in physicians. 

11. Jackson TN, Morgan JP, Jackson DL, et al. The crossroads of posttraumatic stress disorder and physician burnout: a national review of United States trauma and nontrauma surgeons. Am Surg. 2019;85(2):127-135.

12. Cooper B, DeVries J. Promoting staff well-being and success: a work-life balance team initiative. Health Care Chaplaincy Network website.

healthcarechaplaincy.org/caring-for-the-human-spirit-presentations/conference-2018-presentations.html. Presentation at: 5th Annual Caring for the Human Spirit Conference; April 23-25, 2018. See also collected resources on stress and burnout in the medical profession at Stanford Medicine’s WellMD website: wellmd.stanford.edu/healthy/stress.html.

Editor's Note: A book by Kashyap Patel, MD, reviewed in the April issue of Evidence-Based Oncology™, was previously titled, Dying Without Fear. Due to a change by the publisher, Penguin Random House India, the book is now titled Between Life and Death: From Despair to Hope. The book is available August 1, 2020

This review has been updated to reflect the change in the book's title. 

 

BOOK REVIEW: One Oncologist's Journey With a Patient to the Outcome We All Face

Oncology Care First Is a Big Step Toward Bundled Payments in Cancer Care, Authors Say

Oncology Care First (OCF), proposed as the successor to the Oncology Care Model (OCM), will be a major step toward shifting cancer care to bundled payments, according to leaders from an emerging network of community oncology practices.

 published by the American Society of Clinical Oncology, authors from OneOncology highlighted 3 key insights about the OCF, which could take eff ect by January 1, 2021. The Center for Medicare and Medicaid Innovation (CMMI) sent out a Request for Information on November 1, 2019, to replace the OCM, which involves 175 practices in a 5-year pilot to bring risk-sharing strategies to oncology care.

The OCM is built on a fee-for-service (FFS) framework, with practices receiving monthly payments to cover the cost of bringing services to patients that include better care coordination, 24/7 access to medical records, greater access to same-day appointments, and a focus on care planning and survivorship care. Most evaluations of the OCM say it has been good for patients, but that the pricing formulas lag behind the escalating costs of some innovative drugs. While there are similarities to the OCM, the new model has features “that could have a substantial impact on practices that choose to participate,” the authors write.

The OneOncology authors note the following:

• CMS wants to shift some of the FFS payment to capitation, which “will pose challenges for OCF participants.” Evaluation and management (E/M) services and drug administration fees, which were previously outside the monthly practice transformation fee, would be folded inside it.

• Improved performance-based-payment formulas would do a better job of accommodating rapidly rising drug costs‚and protect oncologists from being held responsible for events that are beyond their control.

• New requirements may be added to require practices to gather patient-reported outcomes (PROs).

The potential challenges of gathering PROs were noted during a CMMI listening session, and the Community Oncology Alliance, an advocacy group, has called for this requirement to be phased in. Coauthor Stephen M. Schleicher, MD, MBA, discussed with 

™ the apparent‚ positive changes to the drug reimbursement formula of the OCF, which calls for making pricing adjustments by cancer type.

However, “the bundling of E/M and drug administration services into 1 prospective payment could be a sign of what may come,” the authors write. They compare the proposal with what CMMI tried to do with the Radiation Oncology Model, which faced signifi cant pushback.

Many leading OCM practices have just started the fi rst year of 2-sided or “downside” risk, in which they face the prospect of owing Medicare money if they fail to reach predetermined fi nancial benchmarks. With this in mind, the Community Oncology Alliance (COA), an advocacy group that has pressed for changes to the OCM, has called on CMMI to delay the start of the OCF until January 2022.

“We believe the proposed timeline is not feasible for both participating OCM practices and practices attempting to apply for OCF Model participation without prior participation in the OCM,” COA said‚in its response‚to the November call for feedback. “Some practices have only just accepted a shift to down-side risk in the OCM, and most have not yet received substantial data to help them understand their performance in 2-sided risk.‚Forcing practices with OCM experience to immediately join 2-sided risk in the OCF Model would expose practices to signifi cant volatility due to a range of uncertainties in the proposed payment methodology.”

warn that the shift from OCM to the OCF is a greater transition than practices may realize: “These proposed  changes not only represent a near-term progression toward the CMS’ goal to augment its value-based payment models for cancer, they also provide signals on how CMMI may view the future of value-based care in oncology.”

Young G, Schleicher SM, Dickson NR, Lyss AJ. Insights from the Oncology Care First proposal—where we’ve been and where we’re going in value-based care [published online February 25, 2020].‚JCO Oncol Pract. doi: 10.1200/JOP.20.00015.

Novel Blood Biopsy Detects MRD in Early-Stage Breast Cancer

Metastatic disease is the leading cause of death in the more than 600,000 people worldwide who die of‚breast cancer‚each year. A new blood-based assay to detect minimal residual disease (MRD) in patients with stage 0 to 3 breast cancer was shown to have 100-fold greater sensitivity compared with digital droplet polymerase chain reaction, according to‚results published online‚in‚Clinical Cancer Research.

The new test was developed by a team of Boston-based investigators, who cited the need for “more sensitive liquid biopsies, with greater dynamic range, to identify patients with MRD sooner.” They noted that the new tests could also help identify higher-risk patients in some instances and avoid deleterious treatment in others.

“Our goal is to be able to turn patients who would have developed metastatic disease into patients who won’t,”‚stated‚co-first author Heather Parsons, MD, MPH, a medical oncologist at‚Dana-Farber Cancer Institute‚and associated scientist at the‚Broad Institute‚of Massachusetts Institute of Technology. “In the future, if we can find those patients with residual cancer early enough, determine whether they would benefi t from another course of therapy, and give them an effective additional treatment, we could potentially change the course of their disease.” 

The investigators used retrospective analysis to identify 142 patients who underwent treatment for early-stage disease, tracking their MRD levels after curative-intent surgery at 2 main time points: postoperative (postop) (median, 3.53 months; range, 0.23-8.43) and 1 year out (median, 14.2 months; range, 6.77-21.7). The patients were followed for up to 13 years.

The patients’ tumors were fi rst analyzed via‚whole-exome sequencing‚(WES), with those results used to tailor individualized MRD tests that were run on the patients’ 370 circulating cell-free DNA samples. A median of 57 mutations (range, 2-346) were targeted in each patient. Seventy-eight percent (n = 111) of patients had postop samples available, while 86% (n = 122) had 1-year samples. In addition, the median lead time between the first MRD-positive result and disease recurrence was 18.9 months (range, 3.4-39.2) in the patients with the most mutations tracked.

Distant disease recurrence was shown to be more likely if MRD was detected at the 1-year mark (HR, 20.8; 95% CI, 7.3-58.9) compared with the postop setting (HR, 5.1; 95% CI, 2.0-12.7). Also in these patients, the positive and negative predictive values came in at 0.70 and 0.77, respectively. Overall, the clinical sensitivities were 81% in patients with newly diagnosed metastatic breast cancer, 23% in the postop setting, and 19% at the 1-year mark.

“We’re working to further improve the technology now to catch as many of these patients as possible,” said Viktor Adalsteinsson, PhD, associate director of the Gerstner Center for Cancer Diagnostics‚at Broad. “When we did detect residual disease in blood, following initial courses of treatment, it was a strong predictor of future recurrence. While this was a retrospective study, if a blood biopsy can give clinicians this early warning in real time, that might provide the opportunity to alter a patient’s outcome.”

Despite the positive results, the authors did bring attention to 2 important study limitations. They mentioned how their blood sampling was infrequent, compared with other studies, and took place close to the same time as treatment decisions. In addition, WES was not able to identify enough mutations in every patient. As a next step, the authors recommend that future blood-based assays aiming for extra sensitivity use whole-genome sequencing “to identify more  mutations to track in all patients.” They also call for prospective studies of MRD in breast cancer that can further prove its value to the fi eld.&shy;

Parsons HA, Rhoades J, Reed SC, et al. Sensitive detection of minimal residual disease in patients treated for early-stage breast cancer [published online March 13, 2020]. 

Study Examines Fixed-Duration Therapy in Patients With MM Ineligible for Transplants

Continuous therapy is likely the best choice for most patients with newly diagnosed, transplant-ineligible multiple myeloma (MM), but results of a new study indicate that treatment-free intervals (TFIs) might be a good option for some patients, provided the fi rst-line therapy is effective. MM tends to aff ect the elderly. As many as 45% of new cases diagnosed in the United Kingdom are cases in which the patient is aged at least 75 years. Three in 10 patients with MM are considered frail, meaning their ability to withstand grueling treatment is limited.

At the same time, new advancements in the treatment of the incurable disease are making it possible for more people to live without the cancer progressing.

Continuous lenalidomide and dexamethasone has been shown to boost progression-free survival (PFS), as hasŠcontinuous daratumumab with bortezomib, melphalan, and prednisolone. Newer research has suggested that daratumumab with lenalidomide and dexamethasone isŠalso an eff ective treatment. The combination of an elderly population with new, eff ective treatment options presents a conundrum for some patients and their physicians: What is the best way to maintain or boost quality of life for these patients given the incurability of the disease? In some cases, physicians and patients opt for fi xed-duration therapy (FDT), with TFIs. In other cases, treatment interruptions prove necessary due to toxicities.

, a team of British researchers attempted to understand the results of using TFIs in MM therapy. “In view of the recent shift towards continuous therapy, we looked to evaluate the TFI as an additional metric of effi cacy in routine practice, after 1st and subsequent lines of therapy, in a large cohort of [transplant-ineligible, newly diagnosed MM] patients,” wrote corresponding author Faouzi Djebbari, MPharm (Hons), MSc, of Oxford University Hospitals, in the United Kingdom. To better understand the impact of treatment intervals, Djebbari and colleagues looked at a data set from the UK Thames Valley Cancer Network, identifying patients with transplant-ineligible, newly diagnosed MM who underwent at least 1 cycle of systemic chemotherapy between the years 2009 and 2017.

Patients who had been involved in clinical trials were excluded, leaving a total of 292 subjects. The investigators wanted to evaluate the length of treatment intervals, and also compare them with overall survival (OS) rates and PFS rates. Two-thirds of patients (67%) in the cohort responded to fi rst-line therapy. After that round, the median TFI was 6.9 months. However, after the second round of therapy, the TFI dropped to just 1.8 months. After the third round, the TFI was just 0.6 months.

OS in the cohort was 30.2 months and median PFS was 9.0 months, although the latter varied based on the therapy chosen. The data showed that patients aged over 75 years had inferior OS and PFS rates compared with patients 75 years and younger. 

Djebbari and colleagues concluded that continuous therapy is preferable to FDT for most patients, and thus providers ought to shift toward the former. “However, when continuous therapy is not appropriate due to patient choice, or toxicities leading to discontinuation, an effi cacious (not limited to thalidomide or bortezomib) but tolerable FDT strategy remains a reasonable alternative approach, which can produce a meaningful TFI,” they wrote.

Djebbari F, Sharpley FA, McLain-Smith S, et al. Treatment-free interval as an additional measure of efficacy in a large UK dataset of transplant ineligible myeloma patients. 

. 2020;15(2):e0229469. doi: 10.1371/journal.pone.0229469.

New Study Offers First Direct Comparison Between Venetoclax, Ibrutinib in CLL

Venetoclax has increasingly become a prominent therapeutic option for patients with chronic lymphocytic leukemia (CLL). Now, a new study evaluates its eff ectiveness against another well-known therapy, ibrutinib. Writing in the journal 

, investigators from the United States and United Kingdom note that no such comparison has previously been made between the 2 therapies.

The study comes as treatment of the relapsing/remitting form of CLL (R/R CLL) has been dramatically reshaped by the development and approval of novel agents. Ibrutinib is a Bruton tyrosine kinase inhibitor targeting B-cell receptor pathway signaling. First author Toby A. Eyre, MBChB, of Oxford University Hospitals in the United Kingdom, notes that the drug has shown signifi cant benefit as a monotherapy for patients with relapsing CLL. Another drug, idelalisib, targets the same pathway and has been approved for use in combination with rituximab, an anti-CD20 agent. However, despite improvements in progression-free survival (PFS) among patients who have taken idelalisib, Eyre and colleagues say toxicity concerns have limited its use.

Venetoclax is a B-cell lymphoma—2 inhibitor, approved for use with or without rituximab. “Venetoclax is increasingly utilized at fi rst relapse in combination with rituximab for a 2-year fi xed duration,” the investigators write. “However, to date, no prospective trials have directly compared ibrutinib [with] venetoclax as [first novel agent] (NA1) in R/R CLL.”

Eyre and his team sought to change that by creating a large-scale, international, multicenter study; they utilized data from previous studies evaluating each novel agent. They found data regarding 433 patients who had received ibrutinib or venetoclax as NA1, with or without an anti-CD20 agent. Of those, PFS data were available for 417 patients. Median follow-up was 14.0 months for the patients on ibrutinib (n = 385), and 13.5 months for the patients receiving venetoclax (n = 48).

The primary end points of the study were overall response rate (ORR) and PFS.

The investigators found that ibrutinib was associated with a median ORR of 71% and a median PFS rate of 12%, while patients on venetoclax experienced a median ORR of 96% and a median PFS rate of 56%. Dose interruptions were reported in about one-third of patients in each cohort, and dose reductions were reported in roughly a quarter of patients for both ibrutinib (22%) and venetoclax (26%). Discontinuation rates were 41% for ibrutinib and 25% for venetoclax. In the case of ibrutinib, the most common reasons given for discontinuation were adverse events (22%), CLL progression (8%), and Richter’s transformation (2%), Eyre and colleagues write.

Allogeneic stem-cell transplantation was the most common reason for discontinuation in the venetoclax cohort (10%), followed by CLL progression (4%) and unrelated death event (4%). Venetoclax also had a superior complete response rate, which Eyre and colleagues say likely contributed to its PFS advantage over ibrutinib, but the advantage did not carry over to overall survival.

“In light of this, and in the absence of randomized data comparing these approaches, our data [provide] reassurance that either option remains a reasonable approach as NA1 in R/R CLL,” the authors write. Therefore, they conclude, the choice of an NA1 ought to be based on factors such as “individual patient factors, drug access, deliverability and patient preference.”&shy;

Eyre TA, Lamanna N, Roeker LE, et al. Comparative analysis of targeted novel therapies in relapsed, refractory chronic lymphocytic leukaemia [published online February 20, 2020].ŠHaematologica. doi: 10.3324/haematol.2019.241539.

Policy, clinical, and targeted therapy updates in oncology.

Medical World News: April 2020

Thinking Outside the Box to Elevate, Increase Access to Cancer Care

Evolution. Disruption. Innovation. Telemedicine. A virtual exchange of information. Healthcare has lagged behind in these aspects, but it is necessary to transcend time and distance, according to Susan Dentzer, senior policy fellow at the Duke-Margolis Center for Health Policy, during her presentation “Disruptive Innovations That Could Change the Delivery of Cancer Care” at the Association of Community Cancer Centers 46th Annual Meeting and Cancer Center Business Summit, held March 4 to 6 in Washington, DC. This is her vision for the future of cancer care.

Dentzer spoke passionately about elevating the quality of cancer care delivery by changing the system and asking these questions:

• How do we take the possibilities that exist and expand them?

• What if, instead of a sick-care system, we had a healthcare and health-inducing system that went to the people rather than the people going to it?

Her biggest question of all: for healthcare that mainly involves exchanges of information, not the laying on of hands, why isn’t more of it done virtually today? This is especially pertinent when study results show high levels of patient satisfaction, higher quality of life, less depression, and less stress with telehealth and teleoncology.

According to Dentzer, it is time to think outside the box, incorporating data and technology to elevate cancer care delivery. She provided a telling question from A. Mark Fendrick, MD, coeditor-in-chief of 

, that illustrates how despite advancements in cancer care, obstacles to optimizing its delivery remain: “Why do we have Star Wars medicine on a Flintstones delivery platform? Shouldn’t we at least advance to The Jetsons?”

What many do not realize is that telemedicine, at least the idea of it, has been around since the late 1960s. During her presentation, Dentzer related how Kenneth D. Bird, MD, a former internist and pulmonary specialist at Massachusetts General Hospital (Mass General), developed the first telemedicine system between Logan Airport and Mass General in 1968, with a second link in 1970.

 However, the system was abandoned in the 1970s.

A common theme that ran throughout her presentation was that it is time for healthcare and cancer care to move outside the conventional walls of practices, to not be afraid of innovation, to move closer to patients where they are in their homes and communities. The quality of cancer care needs to be elevated to such a level that it minimizes the amount of time people have to be in the hospital. But doing so first means addressing several important challenges:

• An estimated 70% of US counties lack an oncologist.

• There is an uneven distribution of the overall cancer labor force.

• The aging population has an increasing incidence of cancer.

So, what can we do? What are some examples of opportunities to innovate in medicine?

 This has already been shown to improve access to care and decrease costs, Dentzer noted. Also, with oral cancer drugs and immunotherapies being delivered on an outpatient basis in some instances, teleoncology can help by providing remote supervision of chemotherapy, thereby preventing unnecessary trips to the hospital or doctor’s office.

For example, Boston University’s Biomedical Optical Technologies Lab (BOTLab) has developed a wearable probe, now in clinical trials, that uses near-infrared spectroscopy to measure hemoglobin, metabolism, water, and fat levels in tumors. The University of Arizona created its telemedicine program in 1996 and introduced telemammography between rural locations and the university in the early 2000s; women’s images from a remote location are analyzed within 45 minutes at the university. Lastly, in 1995, Kansas University Medical Center instituted its first teleoncology program with a multidisciplinary team that is 250 miles from a rural medical center, which itself has nurses.

 Abramson Cancer Center in Philadelphia, Pennsylvania, offers genetic counseling in real time, which can be accessed over the phone or through video conference. As this is a service that is not always easy to access, especially when patients are hundreds of miles away, making the counseling more portable can only serve to increase access to care.

Because not all patients need to be seen in the clinic, Seattle Cancer Care Alliance provides a web portal through which they can enter symptoms. This sends an alert to their care team and that alert leads to a phone call.

This is particularly needed for emergency medicine physicians. Telemedicine can increase engagement and communication between experienced oncologists and emergency medicine physicians who may have limited knowledge of immunotherapies and their adverse effects. It also provides opportunities for online learning and 24/7 access to critical care information.

 Denzter pointed out that almost 8 of 10 clinical trials can be delayed, even closed, because recruitment takes too long. Telemedicine can remedy this by “expediting patients’ access to clinical trials” through automated platforms.

“I would argue that the status quo is not an option. You need to take advantage of these capabilities really fast,” Dentzer noted.

1. Dr Kenneth Bird, 73; used TV for diagnosis. 

. nytimes.com/1991/02/16/obituaries/dr-kennethbird-73-used-tv-for-diagnosis.html. Published February 16, 1991. Accessed March 25, 2020.

2. Charlton M, Schlichting J, Chioresco C, Ward M, Vikas P. Challenges of rural cancer care in the United States. 

Healthcare Needs Bipartisan Support to Benefit Patients, Stabenow Says

Before her keynote address, “A Frank Conversation About the State of Healthcare in the United States” during the Association of Community Cancer Centers’ 46th Annual Meeting and Cancer Center Business Summit, held March 4 to 6 in Washington, DC, Senator Debbie Stabenow (D, Michigan), was introduced by Dennis A. Cardoza, cochair of the Federal Public Affairs Practice and chair of the California Public Affairs Practice of Foley & Lardner LLP. He polled the audience with this question: In 2019, healthcare emerged as the top policy issue for Americans. What do you see as the number 1 driving force behind this crisis?

2. Concerns over the cost of treatment on the individual level, high co-pays, deductibles, etc

3. Concerns over the cost to society as a whole

5. Concerns over the quality of care being delivered

Stabenow, a member of the Senate Finance Committee and ranking member of its health subcommittee, followed with her perspective on the state of healthcare costs in the United States today, touching upon how each of the above choices affects healthcare affordability. She reinforced the importance of investing in the country, in public infrastructure, and in public health infrastructure, especially where oncology is concerned, because “it’s about hope. It’s about finding a path. It’s about providing life-saving medications.”

She expressed concerns over the Trump administration’s promotion of short-term insurance plans, from a coverage and treatment standpoint, that don’t have to cover people with pre-existing conditions or that don’t provide the basic coverage called for by the Affordable Care Act (ACA). They are “cheap,” she said, and patients don’t know if they are covered until they get sick, whereas under the ACA, preventive care is covered without a copay.

The Congress is trying to figure out how to not go backward, Stabenow noted, especially in the face of President Trump’s proposed $1.6-trillion cut in future healthcare spending, and “we’re going to work very hard to push back.”

One example is by supporting robust efforts for community health centers and certified community behavioral health centers, because “we predominantly treat these areas not as real healthcare, through healthcare reimbursement, but through grants.” Communities deserve structurally sound, high-quality care.

Stabenow also discussed the cost of vaccines and treatments, shining the spotlight on a recent $3-billion investment in research and vaccines that did not include language guaranteeing that if this research produced effective vaccines, they would be affordable when brought to market. “The federal government should use its power to negotiate a price,” she pointed out. “Keeping the quality high is not worth it if at the end Americans can’t afford the medicine.”

Insulin prices have climbed about 15 times in the past number of years, she said, stressing again that Americans must have access to affordable medications.

“For every one of us, healthcare is not political, it’s personal, and we should all be coming together on every issue, on a nonpartisan basis, to do what we can to make things better, to improve access to care, to improve the quality of care, and to reduce costs,” she concluded. “We can have a difference of opinion in how we approach things. That’s how you get to the good decisions. But we need to not start from a political or ideological position, but from the position of how to make things work.”

Patient Care Must Be an Ongoing Collaboration That Includes Multifaceted Concerns, Panel Says

The theme of the Association of Community Cancer Centers’ immediate past president Ali McBride, PharmD, MS, BPS, BCOP, for his 2019-2020 term was “Collaborate. Educate. Compensate: A Prescription for Sustainable Cancer Care Delivery.” Nowhere was that more evident than in the panel discussion he led on day 2 of this year’s annual conference, which focused on the importance of supporting patients and not just managing the process of their care.

McBride, clinical coordinator, hematology/oncology, Department of Pharmacy, The University of Arizona Cancer Center, was joined on the panel by:

, professor of medicine, Division of Hematology/Oncology, Northwestern University Feinberg School of Medicine

, executive vice president, Health Care, Quality and Value, National Patient Advocate Foundation

, chief executive officer, New Mexico Oncology Hematology Consultants, Ltd; immediate past president, American Medical Association

, ACCC president-elect; medical director, oncology, Penn Medicine/Lancaster General Health, Ann B. Barshinger Cancer Institute

, director, Section of Ambulatory Care Practitioners, Member Relations, American Society of Health-System Pharmacists

, director, Division of Ambulatory Payment Models, Center for Medicare and Medicaid Innovation

The panel discussed the results of Resource and Reimbursement Barriers to Comprehensive Cancer Care Delivery, an ACCC survey originally piloted at the 2018 and 2019 annual meetings that was meant to gauge barriers to delivering the most effective and comprehensive cancer care. Following the 2019 meeting, 172 ACCC member programs responded to questions that covered 27 supportive oncology services, and this panel touched on 5 of them:

Financial needs counseling and navigation

McBride opened the discussion by relating that more than half of the responding oncology practices said they had inadequate resources to provide nutrition, palliative care, financial services, or even genetic counseling. Most offer some supportive oncology services, but these vary in capacity. What they all agreed on, however, was the need for adequate staffing “to deliver supportive oncology services to all patients who need them.”

“We need to create a dissemination strategy to inform policy and oncology reimbursement,” McBride emphasized. “There needs to be sustainable care delivery. How does your organization do this?”

The results? Through the survey, the members of the panel helped develop a tiered, comprehensive cancer care services matrix whose top 5 areas are those mentioned above and explained in further detail below. It addresses such questions as what else is needed to add and/or grow this service and what members of the multidisciplinary team can and/or should provide.

“Navigation is a service, not a job description. Every person a patient comes in contact with has the job of navigating the patient through that part. Navigation is a process that needs to be hardwired into every single member of a team,” McAneny stated.

The panel agreed on the importance of patient navigation being a team effort.

“The idea is that when you meet a patient,” Benson noted, “you can link them with the appropriate person on the team. So start at the very beginning to identify what is important to that patient.”

Cost is also a factor in this area, as there needs to be adequate funds for both the physicians and their patients.

“There needs to be clearly designated time and resources to each team member so they can do their job and it doesn’t become unsustainable over time,” Strawbridge added. “We must recognize the investment in staff and resources and provide rewards in the form of reimbursement.”

Financial Needs Counseling and Navigation

The Association of Community Cancer Centers held its 46th Annual Meeting and Cancer Center Business Summit March 4 to 6 in Washington, DC. 

CONFERENCE COVERAGE: Association of Community Cancer Centers 2020

At this tie of breathtaking innovation in cancer diagnostics and therapeutics, it is easy to become distracted (even mesmerized) by the extraordinary advances in care  technology to the point of losing sight of the fundamental fact that a patient’s cancer journey is a human, not a technological, experience.

Throughout the past 3 decades, as I have spoken with patients and their families about a new cancer diagnosis or a change in their goals of care, our discussions have never focused upon molecular biology, genomics, or abstract ideals about targeted drug design. I have yet to engage any patient or family in a discussion of the arcane details of any of the value-based care models. Instead, our discussions are focused on the more meaningful human dimensions of navigating the flood of emotion that stems from a cancer diagnosis; the focus is upon identifying grounded next steps; finding ways to chart a navigable, sustainable steps of a path that culminates in a restoration to wholeness. For some this is a journey that culminates in a cure; for others the focus is upon recovering a sense of wholeness for a patient and their family when a cure is no longer possible. Each patient travels their respective hero’s journey. The reality is that our technological advancements are simply deployable tools for supporting the patient throughout that journey. How care we more eff ectively use these tools to humanize the cancer journey for patients and their families? How can we put the patient back at the center of patient-centered care? How can we more effective and humanly support the patient’s heroic journey?

™ we explore the human dimensions of the cancer care experience in the hope of better understanding how better systems of care can more effectively serve patients and their families. Maggie L. Shaw provides us with the highlights from the Association of Community Cancer Centers’ (ACCC) 46th Annual Meeting on disruptive, innovative ways to improve patient access to care. Jonathan Nicolla and colleagues discuss ways of using digital monitoring to more eff ectively assess outcomes for patients who are receiving palliative and hospice care. Maggie Salinger, MD, and her colleagues discuss the importance of payment reform in ensuring better and more eff ective access to palliative care. Finally, Florence Caffrey Bourg, PhD, reviews 

Dying Without Fear: The Pursuit of Eternity

From the editor-in-chief of Evidence-Based Oncology™.

April 2020

AJMC® INTERVIEWS: Faculty From the Institute for Value-Based Medicine

BOOK REVIEW: One Oncologist's Journey With a Patient to the Outcome We All Face

Medical World News: April 2020

CONFERENCE COVERAGE: Association of Community Cancer Centers 2020

Putting the Patient Back at the Center of Patient-Centered Care

In Florida, Serving the Senior Population in Oncology Means Working Together

Lack of Clarity on Medicare Advantage Palliative, Other Cancer Care Benefits Limits Consumer Uptake

Why Palliative Care Is the Answer to the Serious Illness Question in Payment Reform

The Need for a Serious Illness Digital Ecosystem (SIDE) to Improve Outcomes for Patients Receiving Palliative and Hospice Care